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Deficiency Records for Autumn Lake Healthcare at Crystal Springs
A list of the most recent deficiencies for Autumn Lake Healthcare at Crystal Springs. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Autumn Lake Healthcare at Crystal Springs. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-22 | 2024-04-15 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-02-22 | 2024-04-15 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2024-02-22 | 2024-04-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-22 | 2024-04-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-22 | 2024-04-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-22 | 2024-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-22 | 2024-04-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-22 | 2024-04-15 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-22 | 2024-04-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-22 | 2024-04-15 | N |
| Post nurse staffing information every day. | Health | 2024-02-22 | 2024-04-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-22 | 2024-04-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-22 | 2024-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-22 | 2024-04-15 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-02-22 | 2024-04-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-22 | 2024-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-22 | 2024-04-15 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-22 | 2024-04-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-22 | 2024-04-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-21 | 2024-03-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-02-21 | 2024-03-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-21 | 2024-03-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-21 | 2024-03-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-02-21 | 2024-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-21 | 2024-03-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-21 | 2024-03-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-08 | 2023-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-08-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-23 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-12-13 | 2023-02-01 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-13 | 2023-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-13 | 2023-02-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-13 | 2023-02-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-13 | 2022-08-08 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-07-13 | 2022-08-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-13 | 2022-08-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-13 | 2022-08-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-07-13 | 2022-08-08 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-07-13 | 2022-08-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-13 | 2022-08-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-13 | 2022-08-08 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-13 | 2022-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-13 | 2022-08-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-13 | 2022-08-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-08-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-13 | 2022-08-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-13 | 2022-08-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-07-13 | 2022-08-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-13 | 2022-08-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-13 | 2022-08-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-13 | 2022-08-08 | N |
| Provide or obtain dental services for each resident. | Health | 2022-07-13 | 2022-08-08 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-07-13 | 2022-08-08 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-07-13 | 2022-08-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-13 | 2022-08-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-13 | 2022-08-08 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-13 | 2022-08-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-08 | 2022-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-08 | 2022-04-01 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-04-07 | 2021-05-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-05-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-04-07 | 2021-05-14 | N |
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